PATIENT FORMS

At EOPCC we value your time. To lessen time spent on registration, please complete and print the following forms and present them to one of our medical secretaries at the time you check-in.

As of August 1, 2009, EOPCC is in compliance with the Federal Trade Commisions Red Flag Rules. Please bring a photo id with you to your appointment. Read our Identity Theft Protect policy by clicking here.

(If you cannot access the forms, click here to download the software needed to access them.)

• Assignment of Benefits

• Financial Policy

• HIPAA Acknowledgment

• HIPAA Notice of Privacy Practices

• Medical History

• Patient Detail Sheet

MISCELLANEOUS FORMS

• Advance Directive - Maryland

• Auto Accident Claim Information

• Authorization for Medical Treatment of Minors

• Durable Power of Attorney

• Financial Hardship Application

• Medical Records Release

• Workers Compensation Claim Information

121-123 W. Main Street • P.O. Box 1219 • Emmitsburg, MD 21727 • Phone: (301) 447-3310 • Fax: (301) 447-5851 • Email: info@eopcc.com
Hours: Mon and Wed 8:30 - 4:00 • Tues and Thurs 8:30 - 8:00 • Friday 8:30 - 5:00